Healthcare Provider Details

I. General information

NPI: 1578292157
Provider Name (Legal Business Name): FAITH ILOMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18060 AZALEA DR
BROWNSTOWN MI
48173-8735
US

IV. Provider business mailing address

18060 AZALEA DR
BROWNSTOWN MI
48173-8735
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone: 734-223-1340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704246256
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: